Three insurance claims scenarios every agent should share with their insured

Insurance companies come across all kinds of claim scenarios. In this article, we will
discuss three different scenarios and the coverages that apply (or may not apply) to
them:
•Slip and fall incident
•FDIC (Federal Deposit Insurance Commission) investigation
•EEOC (Equal Employment Opportunity Commission) charge
•These serve as great insurance claim examples to share with your clients of situations
they may come across, and could help identify an exposure or a gap in coverage they
might have.
Slip and Fall Incident
The claimant, a 34-year-old female, was entering a building where she was employed
when she slipped and fell on icy stairs. This individual sustained a concussion and a
torn medial meniscus of the right knee. The building owner was not responsible for
the claimant’s injury, but rather a third-party vendor hired by the landlord.
In this case, the workers’ compensation policy could respond as she was an
employee in the course and scope of her employment. The workers’
compensation laws of most jurisdictions generally have an “egress and ingress”
rule, which protects employees on the way into or out of their place of
employment. This claimant can collect workers’ compensation benefits, as
workers’ compensation is typically primary in all jurisdictions (first party
benefits). The law also generally includes an “exclusive remedy doctrine” which
holds the employee’s employer harmless from any civil liability. However, when
the injury results from the fault of another party, the claimant can have the
right to sue that third party.
The responsible party in this scenario would likely be the maintenance
company. If the claimant is successful in obtaining a judgment or settlement
against the maintenance company, the workers’ compensation company could
then have a statutory lien against that settlement to offset any amounts paid
pursuant to the workers’ compensation policy. In other words, a portion of the
amount paid under the workers’ compensation claim may be deducted from the
judgment or liability settlement. This can be put into place to prevent the
claimant from “double-dipping.”
FDIC Investigation
In this second scenario, a bank notified its insurance company of an order of
investigation that they received from the FDIC. The order stated that the FDIC was
beginning an investigation and attached subpoenas for nine bank officers and
directors. The bank checked to see if coverage for this situation applied under
its Directors & Officers(D&O) policy for attorney fees they would be charged to
assist with the subpoenas. The bank’s D&O policy provided coverage for claims
first made during the policy period against the bank and insured persons for any
wrongful act. Critical to the determination of coverage was whether the FDIC order
was considered a claim, commonly defined as a formal administrative or regulatory
proceeding commenced by a filing of a formal investigative order or similar
document against an insured for a wrongful act.
Courts are split over whether issuance of a formal investigative order is considered
a claim, or if a formal proceeding is a requirement that must be proven
separately. Even if the court (in the jurisdiction of where this claim took place)
believes the FDIC order of investigation is a claim under the policy, it’s unlikely the
court consider this a claim against an insured for a wrongful act, as the order does
not specifically name anyone as the subject of the investigation. Instead, it says
that directors and officers “may” have violated laws or regulations, and the FDIC is
investigating these potential violations.
In other words, the officers and directors could be witnesses who would be asked
to testify as a part of the investigation rather than be an actual party to the
investigation. Additionally, the order does not specifically say that the bank or
its directors/offices committed any offenses, so it may not specifically allege a
wrongful act. So, even though parts of the “claim” definition from the policy
applies, the complete definition does not.
There may be other ways to obtain coverage for this type of situation. For
example, it is possible that a policy containing subpoena coverage would cover
an order of investigation similar to the example described above. In this
situation, however, the insured had not purchased this separate policy, and was
not covered. This is a great example to share with your bank clients to help them
evaluate their current policy and any gaps in coverage they may have.
EEOC Charge
In this third and final scenario, the insured notified its insurance company of a
lawsuit filed by one of its employees for racial discrimination and wrongful
termination. The lawsuit indicated that in 2016, the employee had filed a
complaint with the Equal Employment Opportunity Commission
(“EEOC”). Both the EEOC complaint and the lawsuit alleged the same
underlying facts. However, the two matters were filed during different policy
periods.
The EEOC complaint was never reported to the 2015-16 Employment Practices
Liability Insurance (EPLI) policy that was in force at the time it was filed, and
because the insurance company issued claims-made and reported policies to this
insured, a significant coverage issue arose (i.e., whether the subsequent lawsuit was
related to the initial EEOC complaint and therefore not covered due to late
reporting).
In the end, the EEOC complaint and the lawsuit were determined to be related and
considered one claim, first made for purposes of coverage under the claims made
policy when the EEOC complaint was filed in 2016. Coverage was denied for the
lawsuit because the claim was not reported to the insurance company within the
required time period required by the 2015-16 policy.
It is important for insureds to be aware of the type of matters covered by their
professional liability policies, as lawsuits are typically not the only matters
identified as “claims” in a claims-made and reported policy. In the scenario
described above, the EEOC complaint was explicitly included in the definition of a
claim. Because the EEOC complaint was considered a claim, it should have been
reported in order to ensure coverage for the subsequent lawsuit.
Check out our blog post, “Employing the Right Coverage: 5 Industries that Need
EPLI” for additional info and insight into what industries should consider getting
an EPLI policy in place.
We Have the Right Coverages for Your Clients
We are continuously evaluating the market and our agents’ requests to deliver new
products from workers’ compensation to commercial insurance. AmTrust has the
coverage designed to help your clients protect their small businesses.
For more details about AMT Warranty feel free to
visit: http://blog.amtrustgroup.com/policywire/insurance-claim-scenarioexamples